Exploring the role of microinstability of the hip: an atypical presentation of femoroacetabular impingement (FAI) and labral tear in a collegiate endurance athlete: a case report.

OBJECTIVE: This case is designed to aid practitioners in understanding the potential role of hip microinstability as a possible underlying source of hip pain and dysfunction. CASE PRESENTATION: A 25-year-old female collegiate cross-country athlete presented with a 2-year history of progressive left hip and groin pain. Extensive clinical examination and imaging confirmed the presence of cam-type femoroacetabular impingement, a labral tear and gluteal tendinopathy. Despite multiple intra and extra-articular pathologies, understanding the role of hip instability and implementing a rehabilitation exercise program focused on hip joint centration alleviated the patient's symptoms at rest and during activity. SUMMARY: A robust history and physical exam of the hip is essential with the addition of imaging when testing criteria is positive. Clinicians should be aware of the role hip microinstability plays and its clinical implications when in the presence of other contributing factors such as generalized joint laxity, and/or intra-articular pathology.

OBJECTIF: Ce cas est conçu pour aider les praticiens à comprendre le rôle potentiel de la microinstabilité de la hanche comme source sous-jacente possible de douleur et de dysfonctionnement de la hanche. EXPOSÉ DE CAS: Une athlète de cross-country collégiale âgée de 25 ans présente des antécédents médicaux de deux ans d'une douleur progressive située au niveau de la hanche gauche et de l'aine. Un examen et une imagerie cliniques approfondis ont confirmé la présence d'un conflit fémoroacétabulaire de type came, d'une déchirure du labrum et d'une tendinopathie glutéale. Malgré de multiples pathologies intra et extra-articulaires, la compréhension du rôle de l'instabilité de la hanche et la mise en oeuvre d'un programme d'exercices de réadaptation axé sur l'articulation de la hanche ont atténué les symptômes du patient au repos et au cours de l'activité. RÉSUMÉ: Une anamnèse robuste et un examen physique de la hanche sont essentiels avec l'ajout de l'imagerie lorsque les critères d'examen sont positifs. Les cliniciens devraient être conscients du rôle que joue la micro-instabilité de la hanche et de ses implications cliniques lorsqu'elle est en présence d'autres facteurs contributifs tels que l'hyperlaxité généralisée et la pathologie intra-articulaire.

Procedure Selection and Patient Positioning Influence Spine Kinematics During High-Velocity, Low-Amplitude Spinal Manipulation Applied to the Low Back.

OBJECTIVES: This investigation compared indirect 3-dimensional angular kinematics (position, velocity, and acceleration) of the lumbar spine for 2 different high-velocity, low-amplitude (HVLA) spinal manipulation procedures (lumbar spinous pull or push), and altered initial patient lower limb posture. METHODS: Twenty-four participants underwent 6 HVLA procedures directed toward the presumed L4 vertebra, reflecting each combination of 2 variants of a spinal manipulation application technique (spinous pull and push) and 3 initial hip flexion angles (0°, 45°, and 90°) applied using a right lateral recumbent patient position. All contact forces and moments between the patient and the external environment, as well as 3-dimensional kinematics of the patient's pelvis and thorax, were recorded. Lumbar spine angular positions, velocities, and accelerations were analyzed within the preload and impulse stages of each HVLA trial. RESULTS: Lumbar spine left axial rotation was greater for the pull HVLA. The pull HVLA also generated a greater maximum (leftward) and lower minimum (rightward) axial rotation velocity and deceleration and greater leftward and rightward lateral bend velocities, acceleration, and deceleration components. Not flexing the hip produced the greatest amount of extension, as well as the lowest axial rotation and maximum axial rotation acceleration during the impulse. CONCLUSIONS: This investigation provides basic kinematic information for clinicians to understand the similarities and differences between 2 HVLA side-lying manipulations in the lumbar spine. Use of these findings and novel technology can drive future research initiatives that can both affect clinical decision making and influence teaching environments surrounding spinal manipulative therapy skill acquisition.

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis. DISCUSSION: Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.

Patient-Induced Reaction Forces and Moments Are Influenced by Variations in Spinal Manipulative Technique.

STUDY DESIGN: An in vivo biomechanical study. OBJECTIVE: The aim of the present study was to quantify and compare the reaction loads for two spinal manipulation therapy (SMT) procedures commonly used for low back pain using a biomechanical computer model. SUMMARY OF BACKGROUND DATA: Contemporary computer-driven rigid linked-segment models (LSMs) have made it feasible to analyze low back kinetics and kinematics during various activities including SMT procedures. Currently, a comprehensive biomechanical model analyzing actual differences in loading effects between different SMT procedures is lacking. METHODS: Twenty-four healthy/asymptomatic participants received a total of six SMT applications, representing all combinations of two similar SMT procedures within three patient hip flexion angles. All contact forces, patient torso kinematics, and inertial properties were entered into a dynamic three-dimensional LSM to calculate lumbar reaction forces and moments. Peak net applied force along with the maximums, minimums, and ranges for each component of the three-dimensional reaction force and moment vectors during each SMT procedure was analyzed. RESULTS: One specific SMT technique (lumbar spinous pull) produced greater maximum anterior-posterior reaction force and both lateral bending and axial twisting reaction moments compared to the other technique (lumbar push procedure [all P ≤ 0.034]). SMT trials without hip flexion had lower maximum medial-lateral reaction force and range compared to those with 45 and 90 degrees of hip flexion (all P ≤ 0.041). There were no interactions between procedure and hip angle for any of the dependent measurements. CONCLUSION: The technique used to apply SMT and the participant's initial hip orientation induced significantly different actions on the low back. These findings and future research can improve patient outcomes and safety by informing clinicians on how to best use SMT given specific types of low back pain. LEVEL OF EVIDENCE: 2.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging.

OBJECTIVE: The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging. METHODS: A narrative review of the English medical literature was performed by using the search terms "hip pain" AND "anterior," "lateral," and "posterior." Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016. RESULTS: Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography. CONCLUSIONS: The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.

Development of a Linked Segment Model to Derive Patient Low Back Reaction Forces and Moments During High-Velocity Low-Amplitude Spinal Manipulation.

OBJECTIVE: The purpose of this paper is to present the experimental setup, the development, and implementation of a new scalable model capable of efficiently handling data required to determine low back kinetics during high-velocity low-amplitude spinal manipulation (HVLA-SM). METHODS: The model was implemented in Visual3D software. All contact forces and moments between the patient and the external environment (2 clinician hand contact forces, 1 contact force between the patient and the treatment table), the patient upper body kinematics, and inertial properties were used as input. Spine kinetics and kinematics were determined from a single HVLA-SM applied to one healthy participant in a right side-lying posture to demonstrate the model's utility. The net applied force was used to separate the spine kinetic and kinematic time-series data from the HVLA-SM into preload as well as early and late impulse phases. RESULTS: Time-series data obtained from the HVLA-SM procedure showed that the participant's spine underwent left axial rotation, combined with extension, and a reduction in left lateral bending during the procedure. All components of the reaction force, as well as the axial twist and flexion/extension reaction moments demonstrated a sinusoidal pattern during the early and late impulse phases. During the early impulse phase, the participant's spine experienced a leftward axial twisting moment of 37.0 Nm followed by a rightward moment of -45.8 Nm. The lateral bend reaction moment exhibited a bimodal pattern during the early and late impulse phases. CONCLUSION: This model was the first attempt to directly measure all contact forces acting on the participant/patient's upper body, and integrate them with spine kinematic data to determine patient low back reaction forces and moments during HVLA-SM in a side-lying posture. Advantages of this model include the brevity of data collection (<1 hour), and adaptability for different patient anthropometries and clinician-patient contacts.

The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed.

Challenges surrounding return-to-play (RTP) for the sports clinician: a case highlighting the need for a thorough three-step RTP model.

Return-to-play (RTP) is a multifactorial process of retuning an injured athlete back to competition when risk for re-injury is minimized. Traditionally, these decisions are made by medical practitioners based on experience or anecdotal evidence. RTP decisions continue to be a challenging task for the medical practitioner. In the interest of advancing sports medicine for the betterment of athletes, improving the RTP decision-making process with a new paradigm has been suggested.1 It stands to clarify the intricacies used by clinicians when making RTP decisions by providing insight into the multiple factors that must be considered; not only by the athlete and medical practitioner, but all relevant parties (i.e., coaches, trainers, and organizations). This case describes a 19-year-old Ontario Junior Hockey League (OJHL) player who fractured his left clavicle during game play and consequently, suffered a more severe injury to the same clavicle 5½ weeks later by returning to competition against medical advice. This case highlights the potential issues that present when a RTP protocol is poorly executed and addresses the need to adopt a thorough decision-based RTP model proposed by Creighton et al.1 Further, the discussion will draw on current literature and issues surrounding RTP, and the potential legal implications associated with premature return to competition. Given the lack of consensus among sport medicine experts in regards to RTP criteria, the presented model stands to provide a pivotal framework upon which future research can be conducted, while improving the current criteria in place when returning an athlete to competition to aid medical practitioners.

Le retour au jeu (RTP) est un processus multifactoriel du retour d'un athlète blessé à la compétition lorsque les risques d'une nouvelle blessure ont été réduits. D'habitude, ces décisions sont prises par des médecins selon leur expérience ou des données empiriques. Les décisions relatives au RTP continuent d'être une tâche difficile pour le médecin. Dans l'intérêt de l'avancement de la médecine sportive pour le mieux-être des athlètes, l'amélioration du processus décisionnel relatif au RTP avec un nouveau paradigme a été suggérée1. Cela vise à clarifier les subtilités auxquelles ont recours les cliniciens dans leur prise de décision relative au RTP en offrant un aperçu des multiples facteurs qui doivent être tenus en compte non seulement par l'athlète et le médecin, mais aussi par toutes les parties concernées (c.-à-d. les entraîneurs et les organisations). Ce cas décrit un joueur du Ligue de hockey junior de l'Ontario (OJHL) de 19 ans qui a fracturé la clavicule gauche pendant le jeu et a subi une blessure plus grave à la même clavicule 5½ semaines plus tard lorsqu'il est retourné à la compétition contre l'avis médical. Ce cas met en évidence les problèmes potentiels qui se posent lorsqu'un protocole RTP est mal appliqué et répond à la nécessité d'adopter un modèle RTP décisionnel proposé par Creighton et autres1. En outre, on y discute des publications scientifiques actuelles et des questions entourant le RTP, ainsi que les conséquences juridiques potentielles associées à un retour prématuré à la compétition. Compte tenu de l'absence de consensus parmi les experts en médecine sportive en ce qui concerne les critères du RTP, le modèle présenté vise à offrir un cadre essentiel à partir duquel des recherches futures peuvent être menées, tout en améliorant les critères actuels dans la décision du retour de l'athlète à la compétition pour aider les médecins.

The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899.

The effectiveness of passive physical modalities for the management of soft tissue injuries and neuropathies of the wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of passive physical modalities compared to other interventions, placebo/sham interventions, or no intervention in improving self-rated recovery, functional recovery, clinical outcomes and/or administrative outcomes (eg, time of disability benefits) in adults and/or children with soft tissue injuries and neuropathies of the wrist and hand. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials, accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text, accessed through EBSCO host, from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 6618 articles and critically appraised 11 studies. Of those, 7 had low risk of bias: 5 addressed carpal tunnel syndrome (CTS) and 2 addressed de Quervain disease. We found evidence that various types of night splints lead to similar outcomes for the management of CTS. The evidence suggests that a night wrist splint is less effective than surgery in the short term but not in the long term. Furthermore, a night wrist splint and needle electroacupuncture lead to similar outcomes immediately postintervention. Finally, low-level laser therapy and placebo low-level laser therapy lead to similar outcomes. The evidence suggests that kinesio tape or a thumb spica cast offers short-term benefit for the management of de Quervain disease. Our search did not identify any low risk of bias studies examining the effectiveness of passive physical modalities for the management of other soft tissue injuries or neuropathies of the wrist and hand. CONCLUSIONS: Different night orthoses provided similar outcomes for CTS. Night orthoses offer similar outcomes to electroacupuncture but are less effective than surgery in the short term. This review suggests that kinesio tape or a thumb spica cast may offer short-term benefit for the management of de Quervain disease.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

A posterior ring apophyseal fracture and disc herniation in a 21-year-old competitive basketball player: a case report.

OBJECTIVE: To describe the diagnosis and management of a competitive male basketball player with discogenic low back pain and presence of an old posterior ring apophyseal fracture (PRAF). This case will highlight the importance of early recognition and considerations regarding patient management for this differential of radiating low back pain. CLINICAL FEATURES: A 21-year-old provincial basketball player presented with recurrent radiating low back pain into the left groin and lower limb. After several weeks of persistent symptoms including pain, muscle weakness, and changes in the Achilles deep tendon reflex, imaging was obtained that revealed a large disc extrusion with an old posterior ring apophyseal fracture. In collaboration with a spine surgeon and family physician, the patient was treated using a conservative, multimodal approach. Treatment consisted of graded mobilizations, spinal manipulative therapy, interferential current, and soft tissue therapy to the lumbar spine. Rehabilitation exercises focused on centralizing symptoms and improving strength, proprioception and function of the lower limb. After a period of 8 weeks, the patient was able to complete all activities of daily living without pain in addition to returning to basketball practice. SUMMARY: PRAF is a unique condition in the immature spine and recent evidence suggests that those involved in sports requiring repetitive motion of the lumbar spine may be at increased risk. The astute clinician must consider this differential in young populations presenting with discogenic low back pain, as a timely diagnosis and necessary referral may allow for effective conservative management to reduce symptoms. Equally as important, one must be aware of the complications from PRAF as a contributing source of low back pain and dysfunction into adulthood. Knowing when to refer for advanced imaging and/or a surgical consult given the variable clinical presentation and prognosis is an essential component to care.

OBJECTIF: Décrire le diagnostic et la prise en charge d'un joueur de basketball de compétition atteint de lombalgie d'origine discale et présentant une ancienne fracture des apophyses postérieures. Ce cas mettra en évidence l'importance d'un dépistage précoce ainsi que des considérations relatives à la prise en charge du patient pour ce différentiel de lombalgie irradiée. CARACTÉRISTIQUES CLINIQUES: Un joueur de basketball provincial de 21 ans présentait une lombalgie irradiée récurrente au niveau de la partie gauche de l'aine et du membre inférieur. Après plusieurs semaines de symptômes persistants parmi lesquels la douleur, une faiblesse musculaire et des modifications du réflexe achilléen, l'imagerie médicale a été obtenue. Cette dernière a révélé une importante extrusion discale ainsi qu'une ancienne fracture des apophyses postérieures. En collaboration avec un chirurgien spécialiste de la colonne vertébrale et un médecin de famille, le patient a été soigné à l'aide d'une approche multimodale conventionnelle. Le traitement consistait en des mobilisations graduelles, en des manipulations vertébrales, en une électrothérapie à courants interférentiels, et en un traitement des tissus mous au niveau du rachis lombaire. Les exercices de rééducation étaient axés sur la centralisation des symptômes et l'accroissement de la puissance, de la proprioception et du fonctionnement du membre inférieur. Après huit semaines, le patient était en mesure de réaliser l'ensemble des activités de la vie quotidienne sans ressentir de douleur et de reprendre les entraînements de basketball. RÉSUMÉ: Les fractures des apophyses postérieures sont un état unique de la colonne vertébrale immature. Des données probantes récentes suggèrent que les sujets pratiquant une activité sportive requérant un mouvement répétitif du rachis lombaire peuvent présenter un risque plus élevé. Les cliniciens avisés doivent tenir compte du différentiel chez les populations de jeunes personnes souffrant d'une lombalgie d'origine discale dans la mesure où un diagnostic en temps opportun et un aiguillage nécessaire peuvent permettre une prise en charge conventionnelle efficace pour réduire les symptômes. Il est tout aussi important et nécessaire d'avoir connaissance des complications associées aux fractures des apophyses postérieures, qui peuvent entraîner une lombalgie et un dysfonctionnement du rachis lombaire à l'âge adulte. Savoir quand se référer à des technologies d'imagerie de pointe ou à l'avis d'un chirurgien au vu de la présentation clinique et du pronostic variables est une composante essentielle du traitement.

Conservative management of an elite ice hockey goaltender with femoroacetabular impingement (FAI): a case report.

OBJECTIVE: To detail the presentation of an elite male ice hockey goaltender with cam-type femoroacetabular impingement (FAI) and acetabular labral tears. This case will outline the prevalence, clinical presentation, imaging criteria, pathomechanics, and management of FAI, with specific emphasis on the ice hockey goaltender. CLINICAL FEATURES: A 22-year old retired ice hockey goaltender presented to a chiropractor after being diagnosed by an orthopaedic surgeon with MRI confirmed left longitudinal and chondral flap acetabular labral tears and cam-type femoroacetabular impingement (FAI). As the patient was not a candidate for surgical intervention, a multimodal conservative treatment approach including manual therapy, electroacupuncture and rehabilitation exercises were implemented. SUMMARY: FAI is prevalent in ice hockey players, particularly with goaltenders. Both skating and position-dependent hip joint mechanics involved in ice hockey may exacerbate or contribute to acquired and congenital forms of symptomatic FAI. As such, practitioners managing this population must address sport-specific demands in manual therapy, rehabilitation and physical training, to improve functional outcomes and prevent future injury.

OBJECTIF: Décrire la présentation d'un gardien de but de hockey sur glace d'élite souffrant d'un conflit fémoroacétabulaire (CFA) de type came et de déchirures du labrum acétabulaire. Ce cas présentera la prévalence, la présentation clinique, les critères d'imagerie, la pathomécanique et la prise en charge du CFA, en mettant l'accent sur le gardien de but de hockey sur glace. CARACTÉRISTIQUES CLINIQUES: Un gardien de but de hockey sur glace à la retraite de 22 ans a consulté un chiropraticien après avoir reçu, de la part d'un chirurgien orthopédique, un diagnostic, confirmé par IRM, de déchirures du labrum acétabulaire chondrales et longitudinales du côté gauche et d'un conflit fémoroacétabulaire (CFA). Comme le patient n'était pas candidat à une intervention chirurgicale, une approche thérapeutique conventionnelle multimodale comprenant la thérapeutique manuelle, l'électroacupuncture et des exercices de réadaptation a été mise en œuvre. RÉSUMÉ: Le CFA est prévalent chez les joueurs de hockey sur glace, en particulier chez les gardiens de but. Les pas de patinage et le mécanisme dépendant de la position de l'articulation de la hanche utilisés dans le hockey sur glace peuvent exacerber les formes congénitales ou acquises du CFA symptomatique, ou y contribuer. Ainsi, les praticiens prenant en charge cette population doivent traiter les demandes propres au domaine sportif en ayant recours à la thérapeutique manuelle, à la réadaptation et à l'exercice physique, afin d'améliorer les résultats fonctionnels et de prévenir les lésions futures.

Juvenile Osteochondritis Dissecans in a 13-year-old male athlete: A case report.

OBJECTIVE: To present the clinical management of juvenile osteochondritis dissecans (OCD) of the knee and highlight the importance of a timely diagnosis to optimize the time needed for less invasive, non-operative therapy. CLINICAL FEATURES: A 13-year-old provincial level male soccer player presenting with recurrent anterior knee pain despite ongoing manual therapy. INTERVENTION AND OUTCOME: A multidisciplinary, non-operative treatment approach was utilized to promote natural healing of the osteochondral lesion. The plan of management consisted of patient education, activity modification, manual therapy, passive modalities and rehabilitation, while being overseen by an orthopaedic surgeon. CONCLUSIONS: Considering the serious consequences of misdiagnosing osteochondritis dissecans, such as the potential for future joint instability and accelerated joint degeneration, a high degree of suspicion should be considered with young individuals presenting with nonspecific, recurrent knee pain. A narrative review of the literature is provided to allow practitioners to apply current best practices to appropriately manage juvenile OCD and become more cognizant of the common knee differential diagnoses in the young athletic population.

OBJECTIF: Présenter le traitement clinique de l'ostéochondrite disséquante juvénile (OCD) du genou et souligner l'importance d'un diagnostic précoce en vue d'optimiser le temps nécessaire pour un traitement non chirurgical moins invasif. CARACTÉRISTIQUES CLINIQUES: Un joueur de soccer de 13 ans, au niveau provincial, présente des douleurs antérieures du genou (récurrentes) malgré un programme de thérapie manuelle en cours. INTERVENTION ET RÉSULTATS: Une approche de traitement multidisciplinaire non chirurgical a été utilisée pour favoriser la guérison naturelle de la lésion ostéochondrale. Le plan de traitement comportait la sensibilisation du patient, la modification des activités, la thérapie manuelle, les modalités passives et la réadaptation, sous la supervision d'un chirurgien orthopédiste. CONCLUSIONS: Compte tenu des conséquences graves d'un mauvais diagnostic de l'ostéochondrite disséquante, telles que la possibilité d'une instabilité articulaire et d'une dégénérescence accélérée des articulations à l'avenir, il faut être extrêmement suspicieux avec les jeunes qui présentent des douleurs récurrentes non spécifiques du genou. Un examen narratif des revues scientifiques est offert pour permettre aux professionnels d'avoir recours aux pratiques exemplaires actuelles pour traiter adéquatement l'OCD juvénile et de se sensibiliser davantage aux diagnostics différentiels communs du genou chez les jeunes sportifs.